Prevalence Rate and Smear-Positivity of Tuberculosis in Infected Patients of Kurram Agency, Pakistan: A Case Study

The present study was conducted to investigate the prevalence ratio of tuberculosis in infected patients of Kurram Agency, Pakistan. A total of 433 cases were recorded from the tuberculosis Center Agency Head Quarter Hospital, Parachinar, Pakistan and analyzed accordingly. Among them, a total of 169 (39.03%) cases were found positive, included males 68 (32.22%) and females 101 (45.49%). The highest prevalence rate was noticed in Parachinar City 87 (48.33%), followed by Tehsil Sadda 51 (43.22%) and the lowest was recorded in Tehsil Ali Zai 31 (22.96%). Regarding age-wise, the highest prevalence 55 (50.47%) was noticed among 41-60 years old patients. Month-wise, the highest prevalence ratio was recorded on January 29 (61.7%) as compared to other months. It has been declared that the Kurram agency is highly burdened by tuberculosis which needs immediate attention of government, local administration and awareness of the general population to combat the issue effectively.

Tuberculosis (TB) is a bacterial disease caused by Mycobacterium tuberculosis which is a major cause of morbidity and mortality throughout the world. It remained the world's leading cause of death for decades [1]. It becomes an active disease and in 75% of cases, it affects the lungs i.e. pulmonary tuberculosis while 25% of cases suffer from extra-pulmonary tuberculosis. The main symptoms include three weeks of prolonged and productive cough, chest pain and coughing up blood [2,3]. Although 95% of tuberculosis-positive cases and 97% of all deaths occur in high-endemic countries, the disease continued to be a problem in industrialized countries as well, mostly in the immigrant population, in elderly individuals with reactivating latent infection, and in local outbreaks [4,5]. About one-third of the world's population is currently infected. Most infected people develop a latent infection and remain in the latency state for many years. At a certain point in time, they may reactivate their old infection, and develop either reactivated infectious tuberculosis or reactivated non-infectious tuberculosis [6]. Based on surveys of the prevalence of infection and disease, assessments of the performance of surveillance systems and death registrations, there were an estimated 10 million new cases and 1.75 million deaths of Tuberculosis in 2015 [7]. Pakistan is the foremost fifth highly burden state among other developing countries, which contributes about 44% to 61 % of tuberculosis burden in the WHO Eastern Mediterranean Region [8-10]. According to a 2016 World Health Organization survey, approximately 356,390 new cases of TB in Pakistan have been estimated in which pulmonary tuberculosis cases were 80% and 4% known cases were HIV co-infected [11]. Studies have shown that socio-economic factors such as poor housing, crowded condition, poorly ventilated spaces, low income, lack of access to medical care, lack of knowledge of tuberculosis prevention are associated with [12]. This study aimed to obtain a reliable estimate of the situation and to determine the number of undetected cases in the 2 communities, the number of persons who have previously had tuberculosis, and the proportion of previously treated cases among undetected tuberculosis patients. The results of this study will be used to plan interventions to control the tuberculosis epidemic in the Kurram agency.

Study area

The present study was undertaken in Kurram agency which is the second-largest agency in FATA, Pakistan. The Kurram agency lies from 32.35 degrees to 33.22 degrees latitudes and 69.22 degrees to 70.38 degrees longitudes. Kurram Agency and Hangu District both join on the north by Afghanistan border, on the east by Tribal areas which joins Karak and Bannu Districts, on the south by South Waziristan Agency and on the west also by Afghanistan border.

Study design

This study was part of a larger community survey (Lung Health Survey) being carried out in the duration of 1 year from January to December 2015. In addition to the prevalence of Tuberculosis, the Lung Health Survey aimed to determine the prevalence of lung diseases, including asthma and chronic obstructive pulmonary disease in the country. However, the current study only deals with the prevalence of TB disease in this locality (Kurram Agency). Information on other lung diseases will be reported elsewhere.

Data collection and analysis

The present study was conducted among different Tehsils of the Kurram agency. A different group of patients admitted at Center Agency Head Quarter Hospital, Parachinar, Pakistan were selected within the age range of 1-60 years and above. Patients having clinical features suggestive of tuberculosis as evening pyrexia, weight loss, productive cough, hemoptysis, malaise, tiredness, anorexia, chest pain, and patients with raised ESR and chest X-ray finding abnormal shadows, cavitations', and/or abnormality in the lymph nodes relative symptoms to tuberculosis were included. A printed Performa containing a comprehensive record of all patients was filled after getting necessary information from each patient. Blood with ESR, Urine R/E, Chest X-ray, Blood Urea, Blood Sugar, and AFB smear examination by direct microscopy were been done for all patients. AFB (Acid-Fast Bacilli) smear refers to the microscopic examination of a fluorochrome stain of a clinical specimen. The sputum specimen was placed on the slide with the help of a wire loop to make a smear with the help of forceps and then an acid Fast stain was put on the sample followed by carbon Fascine for 5 min to fix it on the slide. The slide was washed with decolorized for about 3 minutes. Then Methylene blue was added for a minute to examine under a microscope using a 100 X eyepiece. For more confirmation ICT test was carried out through blood serum collected after centrifugation of blood at high speed. 10 μL of serum was transferred to a special tube designed for the ICT test followed by the addition of 3 drops of buffer solution for 15 minutes. When the T line turned dark, it revealed the presence of TB infection. The data were statistically analyzed and tabulated using the Microsoft Excel version (2010).

In the present study, three tehsils included Parachinar, Sadda, and Ali Zai of Kurram agency, Pakistan were screened for the prevalence of TB. A total of 433 TB patients reports were collected from these regions. Of total 433 reports, 169 (39.03%) were found smear-positive and 264 (60.97%) were found smear-negative tuberculosis patients. The higher incidence of tuberculosis was shown in tehsil Parachinar 87 (48.33%) and the lowest rate of tuberculosis was found in tehsil Ali Zai 31 (22.96%) (Table 1).

The present study showed the overall prevalence of tuberculosis was 169 (39.03%), whereas 68 (32.22%) was noticed in males and 101 (45.49%) in females (Table 2). It was deeply observed that most of the female patients were at higher risk of tuberculosis disease. This was due to the low hemoglobin level in their bodies which made them immunocompromised and reduced the ability to fight the infection. The higher prevalence in females is also due to longer to seek care (patient delay) due to stigma and social exclusion, heavier workloads, prioritization of other family members over own well-being lack of independence inaccessibility to financial resources and Powerlessness in decision making they experience longer provider diagnostic and treatment delays they are engaged in more activities that need to be replaced in the household. In addition, women have higher direct costs than men, because they often need somebody to accompany them they are less mobile and have less financial resources. In district Dir lower, Pakistan total prevalence of tuberculosis, in 2009, documented was 32.23% (males = 45.45% and females = 54.55%) which is lower than our results [13]. The factors for such threatened results indicated are; ignorance, no early medical care, poor hygiene, poorer nutritional status, war and economic depressions, lack of proper treatment protocol, lack of proper health facility and lack of knowledge regarding the treatment and precautionary measures of disease might be putting at risk a large number of people who are living with tuberculosis patients. In 2011, a study from District Dir lower, Pakistan reported lesser prevalence rate of tuberculosis 513 (38.51%), included (males = 46.78% and females = 53.22%) which indicate marked increase in TB prevalence [14]. Another relevant published study from district Upper Dir, Pakistan reported a prevalence of tuberculosis 25.78% (males = 22.42% and females = 28.37%) which is lower than our findings [15]. Additionally, a lesser prevalence ratio 236 (18.15%) of Tuberculosis infection was also reported amongst infected patients admitted at DHQ hospital, Swabi, Pakistan which is in contrast with our reported rate 169 (39.03%) [16].

Similarly, Tuberculosis is highly prevalent (50.45%) in the age group ranging from 41-60 years and this is due to their extensive exposure to the outside environment characterized by poor sanitation and unhygienic conditions (Table 3). Individuals of this age group remain in frequent contact with the industrial environment where they inhale air rich in effluents and dust particles which may cause alveolar inflammation resulting in immune suppression.

Regarding month-wise distribution, results revealed that the higher prevalence was recorded in January (61.07%), while the lowest prevalence was found in November (17.67%) (Table 4). A similar study was conducted in Chakdara town, Pakistan, in which the high TB cases were reported in the month of February (66.66%) which shows resemblance to the results of the present study [17]. On the contrary, a study was conducted in Civil Hospital new Darband region Pakistan, in which a higher prevalence of tuberculosis was reported in the month of October (7.69%) and the lowest (rare) ratio was reported in the month of July (0%) [18].

The present study confirmed that smear-positive tuberculosis has been found in individuals of the low socioeconomic group and females. The patient's family is being always at risk of transmitting the tuberculosis infection. Tuberculosis has caused a tremendous amount of worldwide than any other infectious disease especially in developing countries like Pakistan where it is declared the sixth major cause of death. There were 181/100,000 estimated new cases and 223/100,000 prevalent cases in Pakistan according to 2007 estimates [19]. Early diagnosis and effective treatment of active cases that are infectious to the community is the best way of controlling tuberculosis in our country. The main reason for the increased risk of the manifestation of the disease could the delay in diagnosis and failure to cure a great percentage of smear-positive cases, which might lead to the high death toll ratio and Multi-Drug Resistant (MDR) cases in Pakistan. Currently, for diagnosis, developing countries rely on Acid-Fast Bacilli (AFB) stains and culture and radiographic changes. The conclusion of this study that lockup convicts are at amplified risk for Tuberculosis infection is in line with previous studies driven in the parts of the world [20]. It has been proposed that a Tuberculosis control program should be introduced. There should be special attention for the personages showing a positive family history of Tuberculosis as they have already provoked a chance to gain the manifestation of the disease. Also, deprived sanitation and freshening provide M. Tuberculosis a grand opportunity to persist for extensive periods and transmit it to others. The improvement within ventilation sanitation and overall living conditions in our societies/ houses environment have been suggested thoroughly. We endorse an awareness program for families to acquire knowledge about the possibility of the transmission of M. tuberculosis infection from AFB sputum smear-positive pulmonary tuberculosis. In view, poverty, poor hygiene illiteracy, drug resistance and poor compliance with medications are important reasons for the rising incidence of Tuberculosis.

This study provides pulsating statistics on the Tuberculosis infection condition amongst the Kurram agency, Tuberculosis vestiges are a foremost public health problem focused on the tribal population and there is a need for further Tuberculosis Control programs on a constant and study basis. Targeted programs must engage prisons, jails, HIV/STD programs, specific high-risk occupational groups' illicit drug users, and persons living on the street. Smear-positive pulmonary Tuberculosis is more prevalent in females, in old age individuals and people of low socio-economic groups.

For tuberculosis control, early diagnosis of active cases and their treatment under supervision is important. Effective health education access to treatment centers trained and motivated health care providers can go a long way in making the national Tuberculosis control program a success. Acid-fast staining of sputum is the best method if performed by an experienced microbiologist, as it is reliable and economical. It can be said confidently that such kind of research will play a vital role in the fight against Tuberculosis in Pakistan and especially in the Agency under study. The control measures and prophylactic efforts are required and needed on an instant basis so that to overcome the scenario and to bless the society with sound health.

We are thankful to the Center Agency Head Quarter Hospital, Parachinar, Pakistan for their technical support and assistance in data collection for the present study.

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